Nursing Practice Test V part II with answer

Nursing Practice Test V part II with answer

51. The patient who suffers panic attacks is prescribed

a medication for short-term therapy. The nurse

prepares to administer.

a. Elavil

b. Librium

c. Xanax

d. Mellaril

52. In attempting to control a patient who is suffering

panic attack, the nursing priority is:

a. Provide safely

b. Hold the patient

c. Describe crisis in detail

d. Demonstrate ADLs frequently

53. Which assessment would the nurse most likely find

in a person who is suffering increased anxiety?

a. Increasing BP, increasing heart rate and respirations

b. Decreasing BP, heart rate and respirations

c. Increased BP and decreased respirations

d. Increased respirations and decreased heart rate

54. A patient who suffers an acute anxiety disorder

approaches the nurse and while clutching at his shirt

states "I think I'm having a heart attack." The priority

nursing action is:

a. Reassure him he is OK

b. Take vital signs stat

c. Administer Valium IM

d. Administer Xanax PO

55. In teaching stress management, the goal of therapy

is to:

a. Get rid of the major stressor

b. Change lifestyle completely

c. Modify responses to stress

d. Learn new ways of thinking

56. Another client walks in to the mental health

outpatient center and States, "I've had it. I can't go on

any longer. You've got to help me. "The nurse asks the

client to be seated in a private interview room. Which

action should the nurse take next?

a. Reassure the client that someone will help him soon

b. Assess the client's insurance coverage

c. Find out more about what is happening to the client

d. Call the client's family to come and provide support

57. Mr. Juan is admitted for panic attack. He frequently

experiences shortness of breath, palpitations, nausea,

diaphoresis, and terror. What should the nurse include

in the care plan for Mr. Juan? When he is shaving a

panic attack?

a. Calm reassurance, deep breathing and medications as

ordered

b. Teach Mr. Juan problem solving in relation to his

anxiety

c. Explain the physiologic responses of anxiety

d. Explore alternate methods for dealing with the cause

of his anxiety

58. Ms. Wendy is pacing about the unit and wringing

his hands. She is breathing rapidly and complains of

palpitations and nausea, and she has difficulty focusing

on what the nurse is saying. She says she is having a

heart attack but refuses to rest. The nurse would

interpret her level of anxiety as:

a. Mild

b. Moderate

c. Severe

d. Panic

59. When assessing this client, the nurse must be

particularly alert to:

a. Restlessness

b. Tapping of the feet

c. Wringing of the hands

d. His or her own anxiety level

Situation: Raul aged 70 was recently admitted to a

nursing home because of confusion, disorientation, and

negativistic behavior. Her family states that Raul is in

good health. Raul asks you, "Where am I?"

60. Another patient, Mr. Pat, has been brought to the

psychiatric unit and is pacing up and down the hall. The

nurse is to admit him to the hospital. To establish a

nurse-client relationship, which approach should the

nurse try first?

a. Assign someone to watch Mr. Pat until he is calm

b. Ask Mr. Pat to sit down and orient him to the nurse's

name and the need for information

c. Check Mr. Pat's vital signs, ask him about allergies, and

call the physician for sedation

d. Explain the importance of accurate assessment data

to Mr. Pat .

61. If Raul will say "I'm so afraid! Where I am? Where is

my family'?" How should the nurse respond?

a. "You are in the hospital and you're safe here. Your

family will return at 10 o'clock, which is one hour from

now"

b. "You know were you are. You were admitted here 2

weeks ago. Don’t worry your family will be back soon."

c. "I just told you that you're in the hospital and your

family will be here soon."

d. "The name of the hospital is on the sigh over the door.

Let's go read it again."

62. Raul has had difficulty sleeping since admission.

Which of the following would be the best intervention?

a. Provide him with glass of warm milk

b. Ask the physician for a mild sedative

c. Do not allow Raul to take naps during the day

d. Ask him family what they prefer

63. Which activity would you engage in Raul at the

nursing home?

a. Reminiscence groups

b. Sing-along

d. Discussion groups

c. Exercise class

64. Which of the following would be an appropriate

strategy in reorienting a confused client to where her

room is?

a. Place pictures of her family on the bedside stand

b. Put her name in large letters on her forehead

c. Remind the client where her room is

d. Let the other residents know where the client’s room

is

65. The best response for the nurse to make is:

a. Don't worry, Raul. You're safe here

b. Where do you think you are?

c. What did your family tell you?

d. You're at the community nursing home

Situation: The police bring a patient to the emergency

department. He has been locked in his apartment for the

past 3 days, making frequent calls to the police and

emergency services and stating that people are trying to

kill him.

66. A client on an inpatient psychiatric unit refuses to

eat and states that the staff is poisoning her food.

Which action should the nurse include in the client's

care plan?

a. Explain to the client that the staff can be trusted

b. Show the client that others eat the food without harm

c. Offer the client factory-sealed foods and beverages

d. Institute behavioral modification with privileges

dependent on intake

67. The client tells the nurse that he can't eat because

his food has been poisoned. This statement is an

indication of which of the following?

a. Paranoia

b. Delusion of persecution

c. Hallucination

d. Illusion

68. The client on antipsychotic drugs begins to exhibit

signs and symptoms of which disorder?

a. Akinesia

b. Pseudoparkinsonism

c. Tardive dyskinesia

d. Oculogyric crisis

69. During a patient history, a patient state that she

used to believe she was God. But she knows this isn't

true. Which of the following would be your best

response?"

a. "Does it bother you that you used to believe that

about yourself?"

b. "Your thoughts are now more appropriate"

c. "Many people have these delusions."

d. "What caused you to think you were God?"

70. The nurse is caring for a client who is experiencing

auditory hallucination. What would be most crucial for

the nurse to assess?

a. Possible hearing impairment

b. Family history of psychosis

c. Content of the hallucination

d. Otitis media

71. A patient with schizophrenia reports that the

newscaster on the radio has a divine message

especially for her. You would interpret this as

indicating.

a. Loose of associations

b. Delusion of reference

c. Paranoid speech

d. Flight of ideas

72. What type of delusions is the patient experiencing?

a. Persecutory

b. Grandiose

c. Jealous

d. Somatic

Situation: Helen, with a diagnosis of disorganized

schizophrenia is creating a disturbance in the day room.

She is yelling and pointing at another patient, accusing

him to stealing her purse. Several patients are in the day

room when this incident starts.

73. The nurse is preparing to care for a client diagnosed

with catatonic schizophrenia. In anticipation of this

client's arrival, what should the nurse do?

a. Notify security

b. Prepare a magnesium sulfate drip

c. Place a specialty mattress overlay on the bed

d. Communicable the client's nothing-by-mouth status to

the dietary department

74. The nurse is caring for a client whom she suspects is

paranoid. How would the nurse confirm this

assessment?

a. indirect questioning

b. Direct questioning

c. Les-ad-in-sentences

d. Open-ended sentences

75. Which of the following is an example of a negative

symptom of schizophrenia?

a. Delusions

b. Disorganized speech

c. Flat affect

d. Catatonic behavior

76. The patient tells you that a "voice" keeps laughing

at him and tells him he must crawl on his hands and

knees like a dog. Which of the following would be the

most appropriate response?

a. "They are imaginary voices and we're here to make

them go, away."

b. "If it makes you feel better, do what the voices tell

you."

c. "The voices can't hurt you here in the hospital"

d. "Even though I don't hear the voices, I understand that

you do."

77. A 23-year-old patient is receiving antipsychotic

medication to treat his schizophrenia. He's

experiencing some motor abnormalities called

extrapyramidal effects. Which of the following

extrapyramidal effects occurs most frequently in

younger make patients?

a. Akathisia

b. Akinesia

c. Dystonia

d. Pseudoparkinsonism

78. Which of the following should you do next?

a. Firmly redirect the patient to her room to discuss the

incident

b. Call the assistance and place the patient in locked

seclusion

c. Help the patient look for her purse

d. Don't intervene - the patients need a little bit of room

in which to work out differences

Situation: John is admitted with a diagnosis of paranoid

schizophrenia.

79. You're reaching a community group about

schizophrenia disorders. You explain the different types

of schizophrenia and delusional disorders. You also

explain that, unlike schizophrenia, delusional disorders:

a. Tend to begin in early childhood

b. Affect more men than women

c. Affect more women than men

d. May be related to certain medical conditionsa

80. A patient with schizophrenia (catatonic type) is

mute and can't perform activities of daily living. The

patient stares out the window for hours. What is your

first priority in this situation?

a. Assist the patient with feeding

b. Assist the patient with showering and tasks for

hygiene

c. Reassure the patient about safely, and try to orient

him to his surroundings

d. Encourage, socialization with peers, and provide a

stimulating environment

81. Which of the following would you suspect in a

patient receiving Chlorpromazine (Thorazine) who

complains of a sore throat and has a fever?

a. An allergic reaction

b. Jaundice

c. Dyskinesia

d. Agranulocytosis

82. While providing information for the family of a

patient with schizophrenia, you should be sure to

inform them about which of the following

characteristics of the disorder?

a. Relapse can be prevented if the patient takes

medication

b. Support is available to help family members meet

their own needs

c. Improvement should occur if the patient's

environment is carefully maintained

d. Stressful situations in the family in the family can

precipitate a relapse in the patient

83. While caring for John, the nurse knows that John

may have trouble with:

a. Staff who are cheerful

b. Simple direct sentences

c. Multiple commands

d. Violent behaviors

84 Which nursing diagnosis is most likely to be

associated with a person who has a medical diagnosis

of schizophrenia, paranoid type?

a. Fear of being along

b. Perceptual disturbance related to delusion of

persecution

c. Social isolation related to impaired ability to trust

d. Impaired social skills related to inadequate developed

superego

85. Which of the following behaviors can the nurse

anticipate with this client?

a. Negative cognitive distortions

b. Impaired psychomotor development

c. Delusions of grandeur and hyperactivity

d. Alteration of appetite and sleep pattern

Situation: A client is admitted to the hospital. During the

assessment the nurse notes that the client has not slept

for a week. The client is talking rapidly, and throwing his

arms around randomly.

86. When writing an assessment of a client with mood

disorder, the nurse should specify:

a. How flat the client's affect

b. How suicidal the client is

c. How grandiose the client is

d. How the client is behaving

87. It is an apprehensive anticipation of an unknown

danger:

a. Fear

b. Anxiety

c. Antisocial

d. Schizoid

88. It is an, emotional response to a consciously

recognized threat.

a. Fear

b. Anxiety

c. Antisocial

d. Schizoid

89. All but one is an example of situational crisis:

a. Menstruation

b. Role changes

c. Rape

d. Divorce

90. What would be the highest priority in formulating a

nursing care plan for this client?

a. Isolate the client until he or she adjusts to 'the

hospital

b. Provide nutritious food and a quite place to rest

c. Protect the client and others from harm

d. Create a structured environment

Situation: Wendell, 24 year-old student with a primary

sleep disorder, is unable to initiate maintenance of

sleep. Primary sleep disorders may be categorized as

dyssomnias or parasomnias.

91. The nurse is caring for a client who complains; of

fat?gue, inability to concentrate, and palpitations. The

client stales that she has been experiencing these

symptoms for the past 6 months. Which factor in the

client’s history has most likely contributed to.these

symptoms?

a. History of recent fever

b. Shift work

c. Hyperthyroidism

d. Fear

92. If Wendell complains of experiencing an

overwhelming urge to sleep and states that he's been

falling asleep while studying and reports that these

episodes occur about 5 times daily Wendell is most

likely experiencing which sleep disorder?

a. Breathing-related sleep disorder

b. Narcolepsy

c. Primary hypersomnia

d. Circadian rhythm disorder

93. The nurse is preparing a teaching plan for a client

diagnosed with primary insomnia. Which of the

following teaching topics should be included in the

plan?

a. Eating unlimited spicy foods, and limiting caffeine and

alcohol

b. Exercising 1 hour before bedtime to promote sleep

c. Importance of steeping whenever the client tires

d. Drinking warm milk before bed to induce sleep

94. Examples of dyssomnia includes:

a. Insomnia, hypersomnia, narcolepsy

b. Sleepwalking, nightmare

c. Snoring while sleeping

d. Non-rapid eye movement

Situation: The following questions refer to therapeutic

communication.

95. When preparing to conduct group therapy, the

nurse keeps in mind that the optimal number of clients

in a group would be:

a. 6 to 8

b. 10 to 12

c. 3 to 5

d. Unlimited

96. What occurs during the working phase of the-nurseclient

relationship?

a. The nurse assesses the client's needs and develops a

plan of care

b. The nurse and client together evaluate and modify

the goals of the relationship

c. The nurse and client discuss their feelings about

terminating the relationship

d. The nurse and client explore each other's expectations

of-the relationship

97. A 42 year-old homemaker arrives at the emergency

department with uncomfortable crying and anxiety.

Her husband of 17 years has recently asked her for a

divorce. The patient is sitting in a chair, rocking back

and forth. Which is the best response for the nurse to

make?

a. "You must stop crying so that we can discuss your

feelings about the divorce."

b. "Once you find a job, you will feel much better and

more secure."

c. "I can see how upset you are. Let's sit in the office so

that we can talk about how you're feeling."

d. "Once you have a lawyer looking out for your

interests, you will feel better."

98. A client on the unit tells the nurse that his wife's

nagging really gets on his nerves. He asks the nurse if

she will talk with his wife about nagging during their

family session tomorrow afternoon. Which of the

following would be most therapeutic response to

client?

a. "Tell me more specifically about her complaints"

b. "Can you think why she might nag you so much?"

c. "I'll help you think about how to bring this up

yourself tomorrow."

d. "Why do you want me to initiate this discussion in

tomorrow's session rather than you?"

99. The nurse is working with a client who has just

stimulated her anger by using a condescending tone of

voice. Which of the following responses by the nurse

would be the most therapeutic?

a. "I feel angry when I hear that tone of voice"

b. "You make me so angry when you talked to me that

way."

c. "Are you trying to make me angry?"

d. "Why do you use that condescending tone of voice

with me?"

100. A 35 year-old client tells the nurse that he never

disagrees with anyone and that he has loved everyone

he's ever known. What would be the nurse's best

response to this client?

a. "How do you manage to do that?"

b. "That's hard to believe. Most people couldn't to that."

c. "What do you do with your feelings of dissatisfaction

or anger?"

d. "How did you come to adopt such a way of life?"